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Based on document review and interview, it was determined for 3 of 4 (Pt. #1, #2, and #3) clinical records reviewed for patients placed in restraints, the Hospital failed to ensure that the use of restraints were appropriately ordered, as required.

Findings include:

1. On 4/18/18 at approximately 3:00 PM, the Hospital's policy titled, "Utilization of Restraint and Seclusion" (reviewed 9/6/17) was reviewed and required, "A. Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...b. Physical hold: Holding a patient in a manner that restricts his or her movement against his or her will, regardless of the duration of the hold... C. Restraint for Non-Violent or Non-Self Destructive Behavior... 1. Orders... c. When an RN (registered nurse) initiates restraint, an order will be obtained from a physician... as soon as possible (within 30 minutes) after the restraint is initiated...D. Restraint and Seclusion for Violent or Self-destructive Behavior... 1. Orders... a. Use of restraint... is based upon the order of a physician, including medical staff or house staff..."

2. The clinical record for Pt #1 was reviewed on 4/18/18. Pt. #1 was a 53 year old female, who presented to the Emergency Department (ED) via ambulance on 3/24/18 at 11:00 PM, with complaints of weakness. Nursing documentation on 3/25/18 at 9:06 AM indicated, "Pt became verbally and physically aggressive to tech...Security was called ...Pt refused to go back to on the cart, and was physically placed per security back on cart. The record included a stat (immediately) order dated 3/25/18 at 9:00 AM, for an X-ray of the left shoulder with clinical indication of "left shoulder pain after being restrained". The clinical record did not include any orders for restraint-physical hold, and no documentation of patient being placed on physical hold.

3. On 4/18/18 at approximately 2:00 PM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 66 year old male who came to the ED (Emergency Department) on 4/15/18 due to hypoglycemia (low blood sugar). While in the ED, Pt. #2's clinical record indicated that a RN initiated soft wrist restraints for non-violent behavior on 4/15/18 at 9:05 AM. However, the order for restraints was obtained on 4/15/18 at 1:36 PM (4 hours and 31 minutes after restraints were applied).

4. On 4/18/18 at approximately 2:15 PM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 25 year old male who came to the ED on 3/25/18 with a diagnosis of schizophrenia. While in the ED, the clinical record indicated that Pt. #3 was placed in 4 split restraint (full leather restraint defined by E #5/Manager of ED) due to violent behavior on 3/25/18 from 12:10 AM to 12:54 AM (44 minutes). However, the physician's "Restraint for Violent Behavior" order indicated to use "all side rails up."

5. On 4/18/18 at appropriately 2:35 PM, findings were discussed with E #5. E #5 stated that the order should have been obtained within 30 minutes of restraint application. E #5 added that the physician should have selected the use of split restraint (full leather restraint) for Pt. #3's order.

6. An Emergency Room Technician (ERT- #3) was interviewed on 4/18/18 at approximately 2:50 PM. E #3 stataed that, E #3 explained to Pt #1 that she needed to take her belongings while E #3 checked Pt #1's vital signs. E #3 then took Pt #1's bag and stuff out of the room, and when her (E #3) back was turned, Pt #1 jumped on E #3's back and grabbed and pulled off E #3's earring. E #3 stated another ERT (E #4), along with Public Safety Officer (E #2), came in to assist. E #3 stated that E#4 held Pt. #1's legs because she was kicking.

7. An Emergency Medical Technician (E #4) was interviewed on 4/18/18 at approximately 3:30 PM. E #4 stated that he just arrived on duty when he heard a yell for "help" from the nurse (RN -E #1) and calling for assistance. E #4 stated that Pt. #1 was verbally abusive, swinging her arms. E #4 stated he held Pt. #1's legs for a few minutes and the patient continued swinging her arms, trying to get up. E #4 stated after the security arrived, he left to resume his assigned duty.

8. The ED Manager (E #5) stated the ED does not have physical hold as a restraint, only mechanical or soft restraint. When asked if holding a patient's leg considered restraints. E #5 stated it was her understanding that the security staff receives the CPI (Crisis Prevention Institute) training while the ER staff is trained only in locked and soft restraints. E #5 indicated that ER staff is trained to avoid work place violence and require security to do the hold.

9. The ED Physician (MD #1) interviewed on 4/19/18 at approximately 9:03 AM stated, when asked if a restraint order is needed for physical hold, "no, not for active violence, it is a quick moment. And when security is there I don't tell them what to do."

Based on document review, and interview it was determined that for 4 of 4 staff (E #5, E #8, E #9 and MD #1) interviewed, the Hospital failed to ensure staff recognized physical hold as a type of restraint. This potentially affected the average daily census of 130 patients visiting the Hospital's Emergency Department.

Findings include:

1. The Hospital's policy titled, "Utilization of Restraint and Seclusion" (rev 9/6/17) required, "Definitions/Abbreviations: A. Restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. 1. Inclusions: The following situations ARE considered restraint under this policy ...b. Physical Hold: Holding a patient in a manner that restricts his or her movement against his or her will, regardless of the duration of the hold ... Exclusions: the following situations ARE NOT considered restraint under this policy...C...Physical restriction: Momentary periods of physical restriction by a staff member, without use of material or mechanical devices and with limited force to prevent the patient from harming himself, an associate or other individual..."

2. The Emergency Department "Restraints -ED Skills Day 2017" included, "Types of Restraints...Physical hold: Holding a patient in a manner that restricts his or her movement against his or her will, regardless of the duration of the hold....Exclusion: NOT RESTRAINTS...Physical restriction: momentary periods of physical restriction by staff with limited force to prevent harm." The agenda omitted a portion of the physical restriction language which states "without use of material or mechanical devices."

3. The clinical record for Pt #1 was reviewed on 4/18/18. Pt. #1 was a 53 year old female, who presented to the Emergency Department (ED) via ambulance on 3/24/18 at 11:00 PM, with complaints of weakness. The history and physical included: "Diagnosis H/O (history of) schizophrenia, hypokalemia, intermittent LUE (left upper extremity) weakness... She reports numbness to Rt (right) and Lt (left) shoulder radiating down to her legs; she also reports that her arm started shaking." Nursing documentation on 3/25/18 at 9:06 AM indicated, "Pt became verbally and physically aggressive to tech...Security was called ...Pt refused to go back to on the cart, and was physically placed per security back on cart." The clinical record did not include any orders for restraint-physical hold, and no documentation of patient being placed on physical hold.

4. The Emergency Department Manager (E #5) was interviewed on 4/18/18 and 4/19/18 intermittently. E #5 stated that they (Emergency Department -ED) do not have physical hold as a restraint, only mechanical or soft restraint. When asked if holding a patient's leg was considered restraints, E #5 stated it was her understanding that the security staff receives the CPI (Crisis Prevention Instute) training while the ER staff is trained in locked and soft restraints. E #5 indicated that the ER staff are trained to avoid workplace violence and require security to do the hold on patients. E #5 stated that the yearly restraint training includes restraint application, monitoring, and assessment during restraints.

5. The ED Physician (MD #1) was interviewed on 4/19/18 at approximately 9:03 AM. MD #1 stated, "I don't remember any actual 4 point restraints...; I did speak with the patient after she was restrained." MD #1 stated, "I do not recall what she said, but in the chart it states that she kicked the security guard because he hurt her shoulder." MD #1 stated that a physician's order is not required if a physical hold is used on a patient and stated, "no, not for active violence. It is a quick moment, and when security is there, I don't tell them what to do." MD #1 added, "If we need actual restraints we would need an order."

6. An interview with an ED nurse (E #8) was conducted on 4/20/18 at approximately 10:55 AM. E #8 stated de-escalation and least restrictive methods are used for patients who are combative, before restraints are utilized. E #8 stated the hospital security does the physical hold. E #8 stated that staff might hold a patient's leg to prevent from kicking. In regards to the need for restraint order for the use of physical hold, E #8 stated she would have to defer to the policy, and stated, "It is not something we typically do."

7. An interview with an ED nurse (E #9) was conducted on 4/20/18 at approximately 11:00 AM. E #9 stated the types of restraints that are used are: 4 point lock restraints, soft wrist for medical reason (if a patient is intubated-tube into the body) and lap belt, but rarely used. E #9 was asked if a physical hold is considered restraints, and E # 9 stated only to de-escalate or if the patient is getting ready to be placed in 4 point restraints. In regards to the need for an order for a physical hold, E #9 paused, and then stated, "If it is for a patient safety issue, no order is needed, whatever is safe for the patient."